In this episode of Ethics on Call, Dan and Tom discuss the recent controversy in Catholic circles surrounding the determination of death by neurologic criteria (DNC). The episode features an interview with Dr. Sherri Bracksick, a neuro-intensivist who regularly assesses patients for DNC. Dan and Tom discuss the various options that Catholic health organizations have and offer their own moral analysis of the current American Academy of Neurology guideline.
In this episode of Ethics on Call, Dan and Tom discuss the recent controversy in Catholic circles surrounding the determination of death by neurologic criteria (DNC). The episode features an interview with Dr. Sherri Bracksick, a neuro-intensivist who regularly assesses patients for DNC. Dan and Tom discuss the various options that Catholic health organizations have and offer their own moral analysis of the current American Academy of Neurology guideline.
You can find articles cited in this episode below:
Tom Bushlack (00:00:08):
Hello and welcome to Ethics on Call, the podcast of the Center for Theology and Ethics in Catholic Health. I'm Tom Bushlack.
Dan Daly (00:00:16):
And I'm Dan Daly.
Tom Bushlack (00:00:18):
And today we'll be taking up the recent controversy in Catholic health care and ethics regarding the determination of death via neurologic criteria. So to begin this episode, I just want to state that this is definitely the most complex and technical issue that we've discussed so far in the podcast. And I mean that both from the medical clinical context and also from the theological and ethical perspective. So for those of you who might not be familiar, I want to remind you or inform you that we do have a statement put out by the Center on Death by Neurologic criteria, and that is available on our website at theologyandethics.org under statements, and we will also link to it in the show notes and we'll be referring to that document periodically throughout the podcast as well. So to get us started on our perspective, I want to give a throwback here to something we mentioned in the podcast about Pope Francis's moral theology.
(00:01:18):
And there we talked about a chapter by Andrea Vicini on a discerning bioethics. And I want to read a quote from Vicini, and he's reflecting here on how Pope Francis approaches bioethics. What is complex can be discerned and discernment leads to realistic and even pragmatic analysis decisions and strategies for action. So I think that's the approach we want to take is a discerning bio ethic. Here we are working very hard to be precise in our language and clear about where we have certainty both clinically and theologically and ethically and note areas where this issue is still developing and our moral insight has room to grow. So bringing some epistemological humility to our topic as well. So with that in mind, Dan, would you like to state from the beginning what we will not be covering in today's episode?
Dan Daly (00:02:15):
Tom, I think it is important to note what the podcast isn't about. It isn't about organ donation. These are really distinct issues. Often conversations on brain death quickly move to conversations on organ donation or the context. The reason people are talking about brain death at all is because of organ donation. And really we want to make these, while they're related topics, they're distinct and it's important that the one organ donation does not influence the other brain death. I think one of the things we've seen from some circles is a move toward a more utilitarian approach that when we think about brain death, some folks want to make it easier to determine that people have died via neurologic criteria for the sake of procuring more organs. And we absolutely reject that approach. It's rejected by Catholic teaching. We never instrumentalize a human person. So the discernment here, and I'm glad you used the term discernment, is really about the discernment of whether or not a person is alive or has the person died. So I think that's really the first most important thing that we need to get on the table.
Tom Bushlack (00:03:33):
And on that point, just want to recognize that well, that we recognize there are ethical issues related to organ procurement organization practices, sometimes referred to as OPO, organ Procurement organizations, but that death by neurologic criteria is distinct from those issues. So we're not going to be taking up those separate issues.
Dan Daly (00:03:54):
Yeah, yeah, please, Tom.
Tom Bushlack (00:03:56):
No, go ahead. I was going to throw it back to you for what else we're not discussing.
Dan Daly (00:03:59):
Yeah, and what's interesting is we've heard a lot of people in the industry say, look, we need to look a little bit more closely at OPOs and the ethics of organ donation. I mean, it's a huge issue whether it has to do with brain death or just the practices in general. So again, that may be a topic that we end up taking up in the near term. The other issue we're not going to talk about today is NRP normal thermic regional perfusion. That's a topic that is very complex. It's gotten suppressive late the last few years in this country, and it's really deserving of its own white paper or statement or podcast, but we're not going to take that up. But it's adjacent to the issue of brain death and the central question. So that's not what we're not going to do. But what we really want to do with this is ask, is it morally permissible for Catholic institutions and individuals to use that 2023 American Academy of Neurology? And we're going to abbreviate that during the podcast to a n, the American Academy of Neurology. They put out a guideline in 2023 should Catholic institutions be using that to determine death by neurologic criteria? Because as we'll discuss in a moment, a lot of the debate has to do with that guideline
Tom Bushlack (00:05:25):
And there'll be some other issues coming up along the way, but I think that's helpful to clarify what we're not going to do and maybe take up in other issues because it's really important to keep this question of deaf by neurologic criteria or DNC for short its own ethical analysis and issue. So to start us out, I want to outline how we're going to structure this podcast. We're going to do it a little bit differently and hopefully this will help the listeners to track where we are. So we're going to start by providing some historical context for this issue and outline what we see as the primary issues involved ethically, clinically, theologically in the debate over death by neurologic criteria. Then we're going to shift and we're going to have our first podcast interview guest with an expert in neurology, Dr. Sherry Brax. And then finally, we'll come back at the end and reflect on Dr. Brax six's medical insight in light of Catholic theology and ethics. So Dan, to get us started, why are we talking about this now for people who might not be tracking this issue?
Dan Daly (00:06:30):
So I mean there are a number of reasons, but if we start even this year in February of 2025, there was a brain deaf symposium held at the Catholic University of America in Washington DC and the National Catholic Bioethics Center sponsored it along with CUA. We were a co-sponsor of that. And there the conversation was, as I indicated a little earlier, it was largely on this 2023 a n guideline, and there was a contingent that argued for enhanced testing of the hypothalamus. And as we move forward on the podcast, we'll see why that's important. So we'll say more on that later. But recently there's been this kind of debate within Catholic circles, but that symposium is just capturing what had been going on earlier. And in 2024, a number of scholars put out a piece called Catholics United on Brain Deaf, a Call to Action, and it was signed by a number of other Catholics.
(00:07:35):
And that statement argued that the a n guideline did not establish the person was dead, that it didn't follow Catholic insights about the complete and irreversible cessation of all brain activity so that the a n guideline doesn't actually, the criteria in testing don't assess that. And so therefore, these authors argue that we lack moral certainty that the patient is dead. If we follow the a n guideline, there may be patients who are still alive, who have been declared dead via the a n guideline is the key there. And so they make a number of recommendations. But what are the most important for our listeners is they recommend that health care institutions use criteria and testing that go beyond the a n guideline. And again, the hypothalamus is going to come into play in terms of some of the work that they do in that piece. But if you think about the conversation has been Tom, we'll talk about the long history, but even in the last 10 years, there was a case that many of our listeners will be aware of the case of Jhi McMath, terribly sad case, 12-year-old girl has post-surgery complications that lead to an anoxic brain injury in California.
(00:08:57):
She was declared brain dead, dead by neurologic criteria in 2014. Her family disagreed with that determination. They moved her to New Jersey because their families can choose their standard of death. And so they rejected death by neurologic criteria. All the reports indicate that she went through puberty post brain death determination. She was then declared dead a second time in 2018 removed from all supportive therapy. It's an awful case, but it's a case that got a lot of attention. And that when we went to the symposium, Tom, you'll remember that there was a lot of conversation about Jhi, McMath and some other hard cases as well. And the question there is how could a corpse go through puberty? Some have said this defies common sense. And so the question is, was HAI dead? And if she was dead, how did her corpse go through puberty again? I mean, that's a kind of a question that some people brought up and said, look, it defies common sense. So I mean that's some more recent history that has led us to this point.
Tom Bushlack (00:10:20):
Yeah, Dan, thanks for that review of some of those recent issues. I want to frame this even deeper in terms of historical context for again, some of the listeners that might not be as familiar with the specifics of this issue. In fact, I had to brush up on a lot of this heading into the conference back in January. And really this debate goes back to at least 1968 when the Harvard Brain Death criteria were first published. And I want to note an article that just came out. It's a book chapter by Jason ael, and we can link to it in the show notes that gives a really excellent and easy to follow historical outline of both the events that happened, but then what arguments are at stake in these different events. So in 1968, there was an ad hoc committee from the Harvard Medical School to define what at that time they were calling irreversible coma and the medical criteria for brain death.
(00:11:21):
And that really kind of established the medical criteria for brain death. And interesting to note, you and I both were a little surprised that from the Harvard Medical School, they actually quote Pope Pius the 12th in that article towards the end of it in defense in that distinction that we know so well between ordinary and extraordinary means of prolonging life. So that got the discussion going and really set the standard for medical practice. Then in 1980 and 1981, there was something published called The Uniform Determination of Death Act, the UDDA for short. So we might refer to it that way, the Uniform Declaration of Death Act that was issued by the National Conference of Commissioners on uniform state laws. And that act is the basis for most state laws in the United States today. So some slight variation state to state, but really most state laws draw upon this.
(00:12:24):
And I want to quote from that act. They say the determination of death is achieved when, and this is a direct quote, an individual who has sustained either one irreversible cessation of circulatory and respiratory functions. So that's the more classic definition of death. The cardio respiratory definition or two irreversible cessation of all functions of the entire brain, including the brainstem, is dead. A determination of death must be made in accordance with accepted medical standards, very succinct and very precise, and has proven to be a very durable and useful law. Another important date and event for us to note is in 2000, St. Pope John Paul II made a statement to the International Congress of the Transplantation Society affirming the compatibility of brain death with Catholic teaching. So in that he was affirming the need for medical practitioners to search for biological signs that a person has indeed died, which again is not the same as trying to name the moment when a person dies because that's sort of a mystery that remains a mystery, but looking for the biological signs that a person has died.
(00:13:49):
And in that statement, he defines, he affirms the neurologic criteria for brain death. And again, a direct quote here from John Paul ii specifically, this consists in establishing according to clearly determined parameters commonly held by international scientific community, the complete and irreversible cessation of all brain activity in the cerebral cerebellum and brainstem. This is then considered the sign that the individual organism has lost its integrative capacity. So you'll note a bit of an overlap there, sorry, end an overlap there between what John Paul II said and the language of the UDDA around irreversible cessation of all brain activity in 2008. Then there was a president's counsel on bioethics that took up this issue. Again, as you mentioned before, in 2018, we had the case of Jhi McMath and as we'll unpack in a moment, in 2023, there was a of both the UDDA and the a n guidelines, and then in 2024 there was the Catholics United statement that you mentioned above. So that's a little bit of the kind of broad history to help place this into context. So do you want to say a little bit more, Dan, about the details of that recent reevaluation of the UDDA and the a n guidelines?
Dan Daly (00:15:16):
Yeah, so thanks Tom. So one of the things that I think it's important for listeners to know, some listeners will remember this was in 2023, the Uniform Law Commission took up a possible revision to the UDDA, and ultimately they suspended their work. They didn't carry it through, and there were some controversies about the directions that they were going. Certainly some of those directions would have moved in a way that can conflicted with Catholic teaching regarding whole brain death, that definition that you read from St. John Paul ii. But almost immediately after the UDA revision committee suspended its work very quickly thereafter, the A, the American Academy of Neurology produced its new guideline. And again, that generated some controversy that one of the things that was in there that we're not really going to touch upon today, I don't think, is the change of language from irreversible to permanent, which again, some Catholic commentators think have argued that, look, the language that John Paul offers is of irreversible.
(00:16:30):
So permanent is a different, irreversible means it cannot be reversed. Permanent means we will not reverse. And so there's a kind of a controversy going on there regarding that language. But yeah, as you know, that's been the recent history. And then we've got these kind of the statement from Catholics United, as you noted in the conference. And so it is in the air and there's publications coming out as we speak on this. So yeah, I think to sum it all up, there's a lot going on regarding brain death in the past 10 years, but it really is tying into a much longer, larger conversation.
Tom Bushlack (00:17:14):
Yeah, thanks. So now that we've set up the context and what we see as the major issues involved, what are the theological moral issues that we need to be aware of specifically from the Catholic tradition here?
Dan Daly (00:17:27):
Yeah, Tom, I mean, there's a lot we could choose to discuss here. And with limited time, I don't think our listeners want to listen to a two hour podcast. I'm going to be very selective here. I think the concept that we need to get on the table is the notion of moral certitude. It is in almost every piece on this is a discussion of moral certitude, and it's a debated topic. And so it's a topic that emerged. You could say you could find it in the work of Thomas Aquinas and then certainly developed deeply in the manual list tradition in the 18th and 19th into the 20th centuries, especially 19th and 20th centuries. And there's an excellent piece that Peter Cataldo, who's a well-known, well-regarded ethicist, is going to publish in either late this year, 2025 or early 2026 by our colleagues over at the National Catholic Bioethics Center in their journal, the National Catholic Bioethics Quarterly.
(00:18:38):
And we can't link it in the show notes, but I do recommend that whenever it is published that you read the piece because it's excellent. And what Cataldo argues is that the tradition has endorsed the position that one can act from a solidly probable truth claim, a solidly probable opinion in the language of the Moralists, the Moralists and Cataldo uses Aquinas. He uses Henry Davis, this Jesuit, who wrote a moral manual in English that was really widely read and highly regarded and uses others to develop his account of moral certitude. So it's very much drawing on this deep tradition. And what he says is that an opinion is solidly probable. Remember, you can act from a solidly probable opinion. That's what probable is.
(00:19:35):
You need an opinion that is solidly probable. What is a solidly probable opinion? Well, there are three conditions. The first condition is, is that there's substantial evidence that the claim is true. You have to have some evidence that your position is true. The second requirement is the contrary position can be answered and is not decisive. You have an answer to the other opinion, to the other position, and it does not appear to be decisive upon interrogation. And the final one is that that solidly probable opinion has the support of recognized experts. So here there's an appeal to expertise, which is different than an appeal to authority experts. This is not a time of, we don't live in a time of we're revering experts, but the tradition does revere experts, and in fact, even the ERDs invite people as they make moral decisions in Catholic health care to consult with experts.
(00:20:49):
Think about Aquinas. He argues the probable knowledge emerges from what is true in the greater number of instances or cases. He says, look, your probable knowledge emerges from that from the majority of cases as Cataldo puts it in his piece. So reason has to discern what's true in general, even if there are some exceptions, but it's the kind of majority of cases. So for Aquinas and Theists and theists largely endorsed probabilism. So this gets into the kind of technical history of moral theology, but if you read the Moralists, they largely endorse probabilism. There are some who endorsed equity probabilism or probabilism, but the majority of them, especially as we look in the 20th century, are probabilists.
(00:21:41):
And so especially the most influential ones are probabilists. I think this means that really exceptional cases make for bad ethics. You just need a solidly probable opinion. And maybe I shouldn't put it in that way because solidly probable opinions, as I just noted, are not easy to find. You have to have substantial evidence. The contrary position has to be answerable and is not decisive, and it's supported by a number of recognized experts. As an aside, hard cases or exceptional cases they make for bad ethics, but they also make for bad law and for bad medicine, we don't draw up medical protocols on that one case that we read about in the New England Journal of Medicine. It's from the majority of cases, the overwhelming preponderance of cases. So clearly, Tom, we lack absolute certitude when it comes to this issue of brain death for a number of reasons we'll discuss, right? As you noted earlier, it's a mystery. Death is a mystery. Determining death is not like mathematics. So what are the positions? What are the positions that are kind of on offer at the moment for interrogation?
Tom Bushlack (00:22:59):
Yeah, thanks. And just as a quick aside, I remember learning about probabilism in grad school and thinking, huh, is this a live issue? But all of a sudden here we are, we have more than one probable opinion, at least that's the stance we're going to take. So yeah, we see essentially there are three positions, and again, we outline these in our statement. One would be the acceptance of the current a n guideline. A second one would be the one for those who advocate for enhanced testing beyond what the AAN guidelines provide, specifically enhanced hypothalamic testing. And then the third one would be a complete rejection of the DNC entirely, the death by neurologic criteria standard. So our stance is that we see merit in the first two, and that part of what we're going to discuss for the rest of this episode is going to be that debate.
(00:24:00):
But in light of what we mentioned above about St. John Paul II's endorsement, we don't see rejection of DNC entirely as a solidly probable position. So that's kind of where we're coming from as we continue this discussion. So we've established a lot already. We've got some of the theological resources we want to turn now to look in more detail at the neuroscience of brain death because it is just clinically and medically a very technical and complicated issues. And one of the challenges to finding greater moral certitude in this issue has to do with that very complexity of the science involved. So in order to address that, we have invited a guest to join us. So let's bring her into the conversation now.
Dan Daly (00:24:57):
Now let's welcome our first guest to Ethics on call, Dr. Sherri Bracksick, a practicing neurointensivist. Dr. Braksick is a widely published author and an expert on brain death determination along with Tom and I, Dr. Braksick attended the Brain Death Symposium at the Catholic University of America that the National Catholic Bioethics Center organized and that we the Center for Theology and Ethics and Catholic Health co-sponsored. And that symposium was back in February of 2025. She is well-versed in the current controversies regarding brain death determination. Thank you for joining us today, Dr. Braksick.
Sherri A. Braksick, M.D. (00:25:37):
Pleasure to be here. Thank you.
Dan Daly (00:25:39):
And so first, can you just tell us a little bit about yourself, your background, your experience, and your roles?
Sherri A. Braksick, M.D. (00:25:46):
Sure. So I am a physician, did my medical school graduating in 2011, followed by a neurology residency and then a critical care fellowship finishing in 2017. And I've been practicing as a full-time neurointensivist since that time. At my current position, I am responsible for training our residents and critical care fellows in brain death assessment as part of our practice at my institution. The neurointensivists are the only ones who are doing brain death assessments at our hospital and adults. So I have done easily more than 50 examinations. I don't know how many, but this is a big part of my practice,
Dan Daly (00:26:30):
As you know. And as I just alluded to, there's an ongoing controversy within some Catholic scholarly circles regarding the determination of death by neurologic criteria. So as someone who has obviously used the current criteria many times as you just noted, to determine the death of patients under your care, we do today want to ask you about the current American Academy of Neurology, which we're going to shorten to a n, the N guideline, which is considered the standard. It's a standard but by many people. And we'll ask you about that as well. But before we get into the actual guideline, we just want to ask you about what the experience is like for you as you determine that a patient has died via neurologic criteria. I mean, this cannot be an easy thing to do.
Sherri A. Braksick, M.D. (00:27:18):
No, not at all. If I had my way, I would never have to do this declaration myself. I find them incredibly stressful. It's a huge responsibility to declare a person dead, whether you're going in to listen to their heart to say there's no heartbeat ever again, or if we're doing this assessment, which is very complicated, has a lot of steps to it. When I walk in the morning and know I have these exams to do, it takes hours of my time. And to me, it's the most important exam that person's ever going to have because if I declare a person brain dead, no one's ever going to examine them again. So I feel that in my gut, I feel nauseated every time I do this to make sure I do it the right way. I know that this is used as a pathway for organ donation. I honestly do not care what people decide subsequent to what I say. And if there's any doubt in my mind when I do that exam, I'm just simply not going to declare them. If there's anything on that assessment or anything as far as prerequisites that I'm not satisfied or fixed, then it's not a big deal to me to not declare a person. If I'm going to do it, I'm going to make sure it's an appropriate declaration.
Dan Daly (00:28:32):
So thank you for that. And so as we get into the a n guideline, because this is the guideline that you use, you use the a n guideline, the American Academy of Neurology guideline. Is that true?
Sherri A. Braksick, M.D. (00:28:44):
Correc.,
Dan Daly (00:28:45):
Yes. Does everyone in your position basically use that guideline or is there another guideline that folks will use?
Sherri A. Braksick, M.D. (00:28:52):
Everyone at my institution relies on the AAN guideline. Excuse me. As far as other institutions, I'm not aware of what other guidelines they could use. The current guideline has been endorsed by many other organizations. I think to attempt to streamline this, to make sure we're as consistent as we can be. Pediatrics is now part of the current guideline, and there are some differences in a pediatric examination, but by and large, it follows the same pathway we do for adults. So as far as speaking to other institutions and how they do it, I'm not sure if everyone says AA and guideline is what we're going to do because it's been published before. Hospitals all have their own policies on how to declare brain death, which to me is kind of weird and kind of funny. We should defer to experts who have spent hundreds of hours developing these guidelines based on what evidence does exist and their clinical expertise. So for an individual institution to write a policy on how to do the exam outside of that, to me doesn't make sense.
Dan Daly (00:29:57):
So that gets us to the AI guideline, which you think is the standard, should be the standard, is the standard that you use. What is your evaluation of that current a n guideline? Do you think that it is adequate?
Sherri A. Braksick, M.D. (00:30:09):
I think if you have a physician who understands neurophysiology, who follows that guideline appropriately and knows how to clinically do that assessment at the bedside, that person is a brain dead person. I think where you have to be very careful is having people who don't understand neurophysiology, who don't understand neuroimaging, because you have to interpret the neuroimaging yourself to decide if that image represents an irreversibly damaged brain or permanently damaged brain in the new terminology. And someone who can recognize what prerequisites could be confounding someone's exam and have they adequately fix those. And then you're at the bedside doing the exam. And if you have somebody who understands how to do a neurologic examination on a person without question, then yes, if you follow the guideline, I think that person is brain dead.
Dan Daly (00:31:06):
So earlier you said if you had any doubts you wouldn't, you follow the guideline, but if you had any doubts, you wouldn't declare the patient dead. So are you saying that if you follow the guideline and the patient, I guess I'll ask you to back up. Can you just say what the three criteria are for the determination of death via neurologic criteria?
Sherri A. Braksick, M.D. (00:31:29):
Well, it's more than three I guess if you really think about it, it's every point must be met on the checklist. And for us, we use a 25 point checklist. And the first part is everything you do before the examination, so the neuroimaging and the prerequisites, so laboratory abnormal rallies are corrected, temperatures corrected, blood pressure is appropriate. They have no residual medications on board. And so you can do the math. Have they met their five half-lifes of getting all the medications out of the way? If there's any concern that there was an overdose prior to the hospital stay, have you checked for that? If there's concern for alcohol intoxication, have you checked for that? And then you have the bedside examination where we're checking all the brainstem reflexes from the top to the bottom, is there any evidence that they are aware or reacting to what we're doing?
(00:32:19):
And then the final parts of the apnea test, you take away the ventilator and you see which is the biggest stressor you can give to a person's body. Our drive to breathe happens when we become more acidotic or we collect carbon dioxide, which is the type of acid. And when you allow a person's pH in their blood to become more acidotic, that starts to try to stimulate the medulla, the bottom part of the brainstem to trigger a breath. And so when we do the apnea test, that's exactly what we're trying to do. We're trying to stress that brain to show us it can do anything. And if we go at least eight minutes, it's frequent that we go a little bit longer than that and there's no respiratory effort. And then you check and see, yep, they were acidotic enough that they should have triggered a breath.
(00:33:06):
That's the final part. This ancillary testing, these imaging based studies can be done. They aren't required. And the way I see those, those are not functional studies. What I'm doing at the bedside is seeing if I can get that brain to function at all and what they're doing on the ancillary testing or flow studies, which aren't going to be completely perfect because you might be a millimeter off and on an image. It's hard to tell and things like that. That shouldn't be what we rely on. You should do everything you can at the bedside. If there's something you can't do at the bedside, then yes, absolutely do an ancillary test to try to confirm what you're seeing and to make you as confident as possible. But none of those first three big sections. The prerequisites, the clinical bedside exam, the apnea test should ever be substituted for apnea test. You have to do those first three things as much as you can first.
Dan Daly (00:33:58):
Right? And so when you follow those, you do the testing and the criteria are all met in the typical patient, do you have any doubt that that patient is dead?
Sherri A. Braksick, M.D. (00:34:08):
If there is, I stop the test.
Dan Daly (00:34:09):
Yeah. Okay. So you're operating kind of with this reasonable doubt standard that if you have any reason to doubt, you stop the test and you don't -
Sherri A. Braksick, M.D. (00:34:19):
Stop.
Dan Daly (00:34:20):
You don't declare the patient dead.
Sherri A. Braksick, M.D. (00:34:21):
No, you don't continue. If you look at somebody, you think they took a breath, you're done. You don't do an ancillary test to say, oh, well we can do that instead because I've heard that argument. And that's not simply not true. If there's any evidence that the brain has function, which is what I'm doing at the bedside, you're done and you don't declare that person brain dead.
Dan Daly (00:34:40):
So the next area is, and this gets into function, is there are respected experts such as Christopher DeCock, Daniel Sulmasy, Alan Roberts. They've suggested that we need to add a test to confirm that the hypothalamus is no longer functional because there are situations in which patients don't present with diabetes and citus. And so some of these thickers will say, well, we can't determine patients dead because while the hypothalamus is a part of the brain and it's functioning potentially or it is functioning, therefore we have, but the problem is is that the testing and the criteria do not include the hypothalamus. What do you say to that argument? I mean, that's a really strong argument that's coming from some circles that I think Catholic ethicists and neurologists and Catholic facilities to take really seriously. Do you agree with their call for an enhanced testing protocol?
Sherri A. Braksick, M.D. (00:35:45):
I would not be opposed to it, I'll be very honest because it's a very good argument. How can you say a person is brain dead? If there's a part of the brain you're concerned is working, you shouldn't call that person brain dead. What I will say, most of the patients, the vast majority of the patients I've declared brain dead, have developed a di before I get to them. I can tell you a hundred percent of every patient I've ever worked to declare brain dead is hypothermic, which also is driven by hypothalamic function. So I can confidently say that hypothalamus at the very least is not working correctly. And so then you have to decide because the definition of brain death as a whole brain doesn't work is the lack of concerning enough to not do the exam period. And I can totally see their side of the argument and to kind of reconcile this with myself, how can I do a brain death exam if someone doesn't have di?
(00:36:39):
What I will say is a lot of times, not a lot of times, but a reasonable number of patients who are declared brain dead have had a catastrophic hypoxic injury, cardiac arrest or something like that, and that person has had whole body hypoperfusion. They have not been getting blood and oxygen to all of their body tissues for a certain amount of time. Unfortunately, the brain is just really intolerant of that. And that's why we end up in these situations. But many of them also end up with a kidney injury. And that type of injury would usually be called something called acute tubular necrosis. And the first stage of that is oliguria decreased urine output or anuria, no urine output. And so kidneys who are injured that way would not be able to respond to the presence or absence of vasopressin. So vasopressin is what drives our control of body, sodium, body water and in di vasopressin is essentially absent.
(00:37:34):
It stops being delivered into our blood flow to act on our kidneys to cause sodium and water reabsorption. And so you drain, you lose a lot of body water and your sodium and your blood becomes very high. If you have an acute kidney injury and you stop peeing, you're not going to lose that body water. So that sodium's not going to climb. So you can't clinically manifest diabetes insipidus. So that's one potential reason that may not happen in every patient. And there was another kind of smaller study published out of Vanderbilt in 2022 that is also identifying that vasopressin is produced in the kidneys, at least in some people. And so if you're producing vasopressin outside of the hypothalamus, it's feasible. Those patients may not develop diabetes insipidus. And so that's the way I think about it. Again, I'm certainly never going to do a brain death exam on somebody unless I think their brain really doesn't work anymore. But I totally understand that argument. If diabetes inus is not present in everyone either.
Dan Daly (00:38:34):
And so one of the things that I've heard is that diabetes and TUS is transient. Once it begins, it doesn't continue along always it can come and go. Is that true? And if so, what does that mean in terms of hypothalamic function?
Sherri A. Braksick, M.D. (00:38:51):
I will say in patients who have pituitary hypothalamic dysfunction after a surgery who are not brain dead, they're otherwise awake talking to you, they can often develop a transient diabetes insipidus sometimes called a triple response where they kind of fluctuate and then it evens itself out. And the vast majority of brain dead patients, we don't support on a ventilator long enough. We don't support their bodies on a ventilator long enough to see what happens with diabetes insipidus in the long term. I am aware of some patients who continue to have diabetes insipidus once their bodies continue to be supported, but I'm also aware of some who do not. And so I don't know that we can have a hard and fast rule with that.
Dan Daly (00:39:34):
One of the things that I think we saw at the conference was a focus on a number of hard cases. You'll remember that there was a lot of discussion of the Jahi McMath case from about 10 years ago where she was declared dead via neurologic criteria but then went through puberty. What's your take on the hard cases in terms of what they show us or don't show us regarding brain death assessment?
Sherri A. Braksick, M.D. (00:40:07):
I think those are super hard, and I know nothing about the Jahi McMath case beyond what has been published as no patient I was ever talked about or called about. But what I can say about should a person who's been declared brain deaf should they be able to go through puberty? That's a super, super hard question. I'm an adult neurologist. I don't deal with kids very often. And so this is based primarily on my understanding of endocrine function from medical school and just reading about she went through puberty. That's okay. So how could that work? Is that a feasible thing that could happen and someone who's otherwise clinically brain dead? And so you're reliant on something called GN RH to trigger your hormonal production to stimulate puberty. And GnRH is usually produced in the hypothalamus and then it acts on the pituitary to cause these hormones to be released. And so in looking around when you think about jahi mcath going through puberty after she'd been declared brain dead for quite some time, is my understanding.
(00:41:14):
There has been publications that say that GnRH, that hormone can also be produced outside of the brain and in our gonads, so the ovaries and a girl or in the mammary glands, which are in your breasts. And so I suppose that's a feasible argument that someone could have that hormone then act on the pituitary and trigger puberty. And I can predict the subsequent counter argument to that would be, well, how could a hormone produced in the body get to the brain to trigger that because the brain should not have blood flow. And the pituitary, you could argue, is that really part of the brain? Is it just next to the brain and connected by a stalk, which it physically is. When you look at a brain engross section, there are arteries that travel through the sphenoid sinuses behind our nose that not all patients, but many patients have based on a pathologic study published not long ago, they're called transcellular pituitary arteries that are supplied from the external carotid artery. And so those travel physically through the bone, it can get to the pituitary so that GNRH hormone could feasibly, I mean this is all theory trying to understand how could this happen if Jahi McMath wasn't dean brain dead, but then GRH could reach the pituitary and potentially release those hormones.
Dan Daly (00:42:42):
So the other issue is, so you you're talking here about a child are women who ate fetuses. And so some have said it's a common sense argument that if you can gestate a fetus, you're not brain dead, that corpses can't gestate fetuses or in the Jahi McMath case, corpses can't go through puberty. What would you say in terms of that, these are people obviously who are being supplied, what they need, their organs, their body through medical interventions. But what would you say to the issue of there have been some high profile cases about women gestating fetuses when they've been determined dead via neurologic criteria?
Sherri A. Braksick, M.D. (00:43:26):
I got to be honest, that's a really hard one because I don't have as a non OB and I don't want to keep punting it as the non-specialty, but the way medicine is anymore, it is very subspecialized and I don't understand the hormonal requirements to continue to grow a fetus after someone has been declared brain dead, which would depend a lot on how far along that person's pregnancy was at the time of their injury. And when I think about that, the thing I wonder about also is you think of the brain as an end organ, meaning it's dependent on the blood flow, the oxygen and stuff. And as an end organ, it's what suffers when oxygen drops or when your heart stops beating and the blood flow stops. The baby is also similar to that. It's going to suffer a lot when it's not getting the oxygen and blood flow.
(00:44:19):
It needs whatever the cause of that injury was to that person. If it was something that affected their whole body, it's different. If it was a gunshot to the head that only affected the brain, but if you had a lack of oxygen or a lack of blood flow to your body that's bad enough to damage your brain to that degree, I really worry about how much damage that fetus could have had. But as far as to allow a fetus to continue to grow, I don't think I have the expertise to be able to say, can you, can a body manifest the hormonal requirements to continue that? Because like you said, we're providing nutrition oxygenation via ventilator blood pressure support if they need it by medications otherwise, but what else does that baby need to grow? Is it dependent on the mom's brain? That is the question I'm not a hundred percent sure about.
Tom Bushlack (00:45:08):
I had a question that, going back to something you said earlier, one of the things that we've heard come up has been around the apnea test and potentially a concern that is there risk to damage to the patient? And if so, would we require consent, which of course we can't get consent from someone who is not conscious or responsive on any level. And you described that test and measuring the blood pH and the carbon dioxide level, correct? Is that the right term? Correct. I just want to make sure I say it right. So what would be your response to any of those concerns around whether the apnea test itself is potentially harmful?
Sherri A. Braksick, M.D. (00:45:53):
I wouldn't do something if think, if there's a possibility I'm going to harm a patient. I will say that first I do not think an apnea test is harmful to a person. And the reason I can say that is while we're doing the apnea test, we're taking away the ventilator. So we've just disconnected the tube from the ventilator, but the tube is still in the person's mouth, the endotracheal tube, and so their airway is protected. It's got that tube going down it, it's an open airway, and we put a catheter down there and give them oxygen the entire time because we aren't looking for them to have lack of oxygen. Again, we're looking to can we trigger them to breathe? And so we need to stress their body, but I don't think that stress is causing anything that's harmful to them. And the reason I say that these patients will drop their pH, a normal pH is 7 3 5 to 7 4 5, 7 0.35, 7.45. And these patients, the AAN requirement says it needs to be less than 7.3. By and large, they drop much closer to seven, 7.0, 7.1 something. But I work in the ICUs, I see patients with all kinds of critical illness, and I've seen patients present with a pH of 6.8 or less. And if you can fix that, they can recover and have normal neurologic and normal body function. So I don't think this very transient acidosis that we induce is worsening anything.
Dan Daly (00:47:16):
So as we continue to think about this, are there ways that this protocol that the criteria and the testing could be improved? Are there ways that you would suggest either whether it's the guideline or how it's implemented, is there anything in this area that you think needs improvement given that there is a dialogue, a discussion going on right now about the need to improve the a n guideline?
Sherri A. Braksick, M.D. (00:47:43):
For me, myself, I feel very comfortable that I understand how a normal brain works, how physiologically and pathophysiologically injuries affect the brain. And I don't have a concern with the way the AA and guideline is now where I think there could be a gap and that we need to have improvement is that not everyone who does a brain death assessment at the bedside. As a trained neurologist, I have the privilege of working at a place where there's six of us and we are all trained as neurologists, all trained as neurointensivists, and we all talk to each other quite often about pretty in depth neurophysiology, neuropathology things. And so I feel like I have a very good understanding. My colleagues have a very good understanding of what a catastrophic irreversible permanent brain injury is. I do worry or wonder because of a paper I published before about competence of individual providers, and we have this guideline, and if it's followed to a T by someone who understands every piece of that guideline, I feel like those patients are appropriately declared brain dead.
(00:48:55):
I wonder if you have somebody who doesn't have a good understanding of neurophysiology, how do we assess their competence? How do they understand? Can they look at an MRI, the way I look at an MRI or a CT scan, the way I look at a CT scan and that patient's exam and truly complete the exam in a technically appropriate and accurate manner or interpret the imaging as a permanent injury? And that's more than just reading a report. You have to actually look at the pictures and say, is this entire brain irreversibly or permanently destroyed is a very strong word, but is there no way for that brain to recover from what has happened to it? And I think those two points are the biggest thing for the rest of the guideline, because if you have a competent person who can interpret every piece of those prerequisites and do an accurate bedside exam, then I think that the guideline's fine.
(00:49:54):
I do think it would not be unreasonable to require some sort of assessment of competence, but what that is is not entirely clear to me. The Neurocritical Care Society has a course that now that you can get certification in a brain death assessment, which at the very least that's an easy thing that someone could sign up for and do, and you have people overseeing that course who would be considered the world experts in it, the guideline authors are involved in that. So I guess that's what I would say most. And like I said earlier, I understand the argument about the hypothalamus. If that becomes part of the guideline, I would not be upset by it. I don't necessarily feel it's a hundred percent necessary based on my understanding of the physiology and the pathophysiology.
Dan Daly (00:50:45):
Well, great. Well, Sherry, excuse me. Dr. Brak, thank you so much for your time and your expertise. We are really grateful and it really does help us and our listeners further understand this really complex and controversial topic. So thank you again for your time.
Sherri A. Braksick, M.D. (00:51:03):
Yeah, thank you so much for having me.
Dan Daly (00:51:05):
Thanks for being here. Appreciate you.
Tom Bushlack (00:51:13):
Wow, Dan, that was certainly a lot to unpack and we're really grateful for Dr. Braksick's experience and sharing that with us. So now we really want to practice what we talked about is that discerning bioethics and provide our analysis of the ethical reasoning related to the medical science that she just articulated. So I'm just going to walk you through and ask you to apply those three conditions of moral certitude to the current a n guidelines, and I think that'll help us move through this analysis. So that first condition, is there a substantial evidence that the A and guideline and criteria and testing assess death?
Dan Daly (00:51:55):
Tom, I think there is is substantial evidence when you think about what the a n guideline with the three criteria are, that there's a cone with known cause excluding all confounders, such as pharmaceuticals of the system, yeah, you name it, hypothermia, brainstem, aleia, and a positive apnea test. So those three criteria with all the tests come with those. We can talk about those. This is a functional assessment of the whole brain, which is exactly what John Paul II and the UDDA ask for. So again, you noted earlier those are in line John Paul II and the UDDA really are asking for that kind of whole brain functional assessment is their function of the whole brain. And I think these tests demonstrate that the whole brain, if the patient is determined that the brain is not functioning in these three ways, there's substantial evidence here that the brain is no longer functional. Remember Dr. Brax said that she has a 25 point checklist. This is exhaustive as she noted. It takes an enormous amount of time. It's done very carefully. I think there is substantial evidence that this criteria in these tests do actually assess whether or not a person is alive or has died.
Tom Bushlack (00:53:25):
Great. So we've met that first criteria. Then the second one asks us whether can the contrary position be answered?
Dan Daly (00:53:35):
And here that contrary position is, do we need is a test for hypothalamic function necessary, which some are suggesting. You'll remember what Dr. Brak said was, well that test, she wouldn't be opposed to that test, but she doesn't think it's necessary.
(00:53:55):
So she's kind of got a nuanced position there. And I think when we think about the hypothalamus, we have to remember that no one has ever claimed that every brain cell must be dead or have already undergone putrefaction in order for a person to be declared dead. So that's never been a position. I don't think that's necessary because what we're talking about is integrative activity, not just cellular activity. It's that there's integration. So activity, if we follow John Paul's language, because John Paul actually uses the word activity, shouldn't be interpreted as individual cellular activity in the brain, but rather that integrative active activity or function of the brain and integration involves complex relationships among the parts of the body as a living whole, whether it's the brain and other parts, but that there's this kind of complex relationship and communication and the hypothalamus can't achieve that kind of integrative relationship or activity alone. It simply can't. So while there may be cellular activity of the hypothalamus, there is also cellular activity in other parts of the brain at the very same time in and other organs. So other organs, in fact, we found in a 2023 study can even produce vasopressin, which is that neuroendocrine hormone that provides a lot of the regulatory functions that the hypothalamus performs. So there are other possible avenues of production of vasopressin within the body.
Tom Bushlack (00:55:46):
So we do have a probability that the contrary position can be answered but not definitively cleared. So we're still in agreement with that second condition. And then the third condition is this position of following the current AAN guideline endorsed by experts.
Dan Daly (00:56:07):
And so I think if you look at the field, the vast majority of neurologists endorse the AAN guidelines. So that's one set of experts, but other experts do as well, such as Catholic ethicists. So you've got multiple, we wouldn't simply ask neurologists, but the majority of Catholic ethicists practicing in this field, were aware of the issue endorsed the a n guideline as a guideline that can determine death. Tom, right after that conference, so in March of 2025, I did a little tour of some Catholic health facilities that do brain death determination regularly. And I met with over a hundred neurologists through a series of grand rounds and individual meetings and group meetings, and every single neurologist that I asked about this, and I talked about moral certitude and I talked about the positions that were coming out of the conference. I genuinely, in the spirit of inquiry, wanted to know what their perspectives were on this and kind of pushed them. In fact, at times, not one of them doubted that a person had died when the a AAN guideline had properly been followed, not one of them. And so again, these are neurologists practicing in our Catholic medical facilities.
(00:57:33):
And again, I would invite us to recall what Dr. B Bra said that she has no concerns about the AAN guideline, but she's also not opposed to that additional hypothalamic testing either. So again, as I said earlier, nuanced position, she said the AAN guideline is sufficient so that hypothalamic testing is not necessary, but she's not opposed to it. So she's seeing that maybe there's growth in a way, but it's not necessitated, at least at the moment. So I think what the conclusion is based on this analysis is this is a solidly probable position. It's a solidly probable position. Now, does that exclude the possibility that the other position is true? It doesn't. So the other position that Sal Maze and Roberts and Cock quite articulately developed could be true. So that's also a solidly probable position. I think we didn't run the analysis on that, but I think it could be considered a solidly probable position. But I think when we have these two solidly probable positions and the one that we've defended and discussed today doesn't violate any Catholic teaching, and people who act from that the solidly probable position, have a level of moral certitude, then we can in good conscience follow the 2023 AAN guideline in Catholic medical facilities, whether a person is an individual or an institution via policy.
Tom Bushlack (00:59:15):
And I think that's an important point just to underscore that in good conscience, we feel solid that practitioners can follow those guidelines. And it is possible that other forms or further testing could be, that's a probable opinion to explore that we respect those who are articulating that claim as well.
Dan Daly (00:59:40):
So Tom, as we move toward closing this conversation, just curious about some of your takeaways given what we heard from Dr. Brax and just our own reflections,
Tom Bushlack (00:59:49):
Again, so much to bring together into these strands, but we want to leave again, whether it's ethicists or medical practitioners, neurologists, or even administrators working in Catholic health with some of these takeaways. And again, these are similar to what we have in that statement as well, but we've just unpacked the reasoning at a much greater depth here in this podcast. So again, we do support that brain death as a standard for determining death alongside of the more traditional or more ancient cardiac cardiorespiratory determination. Again, following from the statement by St. John Paul II in 2000, and our further analysis of applying that probabilistic argument to the state of the question in light of Catholic moral teaching broadly understood. So we also accept the American Academy of Neurology as a medical society with the appropriate professional competence to recommend those brain death criteria and testing. So again, there's nothing precluding there being other standards, but as far as we know, there aren't any that are broadly informed by that level of medical expertise as well as accepted in the discipline. And again, worth reiterating, our appeal here is to expertise but not simply authority because of role, right? Expertise based on experience, which is that third condition of it being a probable argument.
(01:01:26):
We maintain that the three criteria for assessment of brain death in the 2023 guideline, and again, those three broadly are coma with a known cause. So ruling out confounding variables that might cause it brainstem, a reflexion and apnea. And again, we could drop that down into, as Dr. Brak talked about, those are the big three, but she has a 25 point checklist that those guidelines, that guideline does provide moral certitude for the determination of death. And our statement isn't necessarily that this is the best or the only guideline that could be followed, but simply that there's nothing in that guideline in our analysis that conflicts with Catholic theology or ethics. Again, dealing with our subject matter here, we're never going to have a perfect guideline. Going all the way back to Aristotle, who of course influenced Thomas Aquinas every science. And for those listeners not familiar, Aristotle considered ethics a science.
(01:02:33):
We don't tend to think of it that way in the modern world, but in the way he understood science, each science admits of only so much precision as the particular subject matter can offer. So when we're dealing with ethics, we're dealing with very contingent, particular complex instances of human action and choice. So in this sense, we don't expect our ethical analysis to be like a mathematical equation. So that's why the whole tradition of probabilism has arisen. So we're not expecting absolute certainty. We're certainly not saying we know in the moment of death occurs, but rather that the guideline provides us enough moral certainty to say that a person is biologically dead at that point.
Dan Daly (01:03:21):
Yeah. Tom, it reminds me of something you said earlier, and we revisited it a little bit earlier as well, is the notion of mystery. I mean, death is a mystery. Life is a mystery. Death is a mystery. And the great existentialist philosopher Gabriel Marcel has some work on mystery. What he wrote was that mysteries are realities that intimately involve the person life and death. These intimately involve us and people we love, mysteries can be entered into, but they cannot be finally comprehended. We can learn more and more about a mystery, but we can't, again, this is not mathematics. It's not reducible to something that we can easily communicate and Aquinas had the same perspective, right? The theology looking at ultimate mystery at God, who is ultimate mystery can never be comprehended. But we can progressively understand mysteries more clearly even if we can't finally comprehend them. And really, I think this discourse is attempting to do that. It's attempting to progressively understand this mystery, the mystery of death a little bit more clearly as we enter into these dialogues and debates.
Tom Bushlack (01:04:35):
Yeah, that's a great point, Dan. And a good kind of humbling reminder that we're dealing with bigger issues of human life and death here. And I think as Dr. Brax six stated really well, for those who do these assessments, it probably is one of the most difficult things they will do in their entire professional careers. And anyone, whether it's a patient, family member care team, we are by definition dealing with a tragic situation already. So bringing that humanity into this as well. So thanks to that point. Going back to some of our takeaways, we do as a center, want to encourage Catholic health providers to continue to ensure that strict separation between the clinical assessment of death, whether that's by neurologic or cardio respiratory criteria, to separate that from decisions regarding organ donation. As we said at the beginning, that's we want to make sure there's a distinction between those two issues and that they don't get conflated.
(01:05:40):
And there may be other points where we take up the question of organ donation, but for now, what we want to say is that the determination of death needs to be entirely separate from any decision about organ donation. And again, Dr. Brax I think did a nice job of saying, as a neurointensivist, I don't care what their decision is about that, that's not my job. Right? She's focused on that. And then finally, I think the point that she made and that we agree with is that further research into professional standards for qualification, or perhaps even certification for providers charged with determining brain death is certainly warranted and worth exploring. That's an issue for the field of neurology to deal with, but we can certainly lend our support to that as a center. So that kind of summarizes where we stand. And again, that's all in our position statement. Dan, any final thoughts as we wrap up our discussion here?
Dan Daly (01:06:45):
Well, I think, Tom, I think it's important for us to remember that, and we have been engaged in this dialogue with others, and I think dialogue and even debate are healthy. This is how we remember our times in seminars and debating each other and engaging in these dialogues. We refine our positions. We need this kind of work. The history of theology is full of this kind of work. It's incredibly healthy and in fact necessary. So it's helping us to refine our position. Hopefully others are refining theirs and dialogue with us and others. But what the problem is, is that we often see today is that when dialogue and debate devolve into, they become unhealthy when they devolve into a culture war issue, culture wars, any war is about winning. Wars are fought to be won. And this isn't about winning. It's not about one position prevailing over the other.
(01:07:50):
It's about the discovery of truth. So true dialogue and debate are inquiries dedicated to that discovery of truth, and they always have to begin in intellectual humility and intellectual charity. You can't practice intellectual charity and engage in the culture war at the same time. And I think that's important. And I think the position that we've taken here is a nuanced one, right? We're saying we have a solidly probable position. There may be other solidly probable positions as well, and we need further refinement. We need further dialogue and debate in that spirit of intellectual humility and charity.
(01:08:30):
And so history has really shown that war is a terrible way and terribly ineffective, way, terrible and ineffective way to convert people. Ultimately, the pursuit of truth is we try to discover the truth in so far as we can and we can, but because of our human limitations, we will never perfectly understand. But we try to do it as well as we can so that we can share that and convert others. But again, you don't convert through war. And whenever it's been tried, it's failed miserably. So that's why we kind of need that dialogue. And so again, I guess the sum for me is the acceptance of the a n guideline and those who might argue for an enhanced testing protocol, I think they're probably both solidly probable, which means the Catholic institutions and individuals are free to choose among those. But I do want to invite us to a further conversation regarding this because I think it's important, and I don't think anything has been, the issue isn't fully determined or settled at the moment.
Tom Bushlack (01:09:48):
Yeah. Thanks for spelling that out clearly. Again, and I think that's a key point to end on, is that historical perspective, that it's through this kind of disagreement in good faith and charitable, assuming the goodwill of even those we disagree with, that's how the Catholic moral theological tradition has developed over the centuries. And I guess it's axiomatic of our center that we trust that through further study, prayer, reflection, dialogue, we can always arrive at greater appreciation and articulation of the truth, greater clarity. And we certainly look forward to continuing to engage in that dialogue and discussion that can get us there along the way.
Dan Daly (01:10:36):
Right. Well thanks Tom. So for Tom Bushlack, I'm Dan Daly, and this has been Ethics On Call. You can find this podcast on YouTube, Spotify, apple, and our website, theology and ethics.org/podcast. And if you're on one of those podcast platforms, would ask that you follow or subscribe to our page and leave a five star review and some feedback about the show. We'd love to hear from you. We'll talk to you soon.